Cas cliniques

DOI of or

CorrespondMaimonides MUSA, E-mail:

Ann Vasc SurgDOI: 10.1016/� Annals of V�Edit�e par ELS

Recanalisation spontan�ee d’une art�erecarotide interne occluse

Parth S. Shah, Anil Hingorani, Enrico Ascher, Alexander Shiferson, Nirav Patel, Kapil Gopal,

Brooklyn, NY, USA

La recanalisation apr�es une occlusion d’une art�ere carotide interne extracranienne (ICA) est unph�enom�ene rare et l’histoire naturelle de la maladie est en grande partie inconnue. Il y a peu decas rapport�es dans les s�eries publi�ees, incluant les recanalisations pr�ecoces apr�es un accidentc�er�ebrovasculaire (AVC). Nous rapportons le cas d’un homme de 74 ans qui s’est pr�esent�e avecun AVC et une histoire d’AVC multiple dans le pass�e, le dernier �episode remontant �a un an. Lesmodalit�es multiples d’imagerie, y compris des duplex, des angioscanners, et une angiographieguid�ee par fluoroscopie des deux art�eres carotides, montraient une occlusion ant�erieure de l’ICAgauche. Le duplex fait 8 mois plus tard montrait la recanalisation spontan�ee tardive de l’ICAgauche occluse. Le patient a eu une endart�eriectomie carotidienne avec succ�es. La physio-pathologie, l’histoire naturelle, et la strat�egie possible de surveillance sont discut�ees dans cetteobservation.

Spontaneous early recanalization of the internal

carotid artery (ICA) or intracerebral arteries after

an acute occlusion is a known phenomenon1,2 and

usually occurs early, between 6 hours and 2 weeks

after the event.3,4 By contrast, late spontaneous

recanalization (>6months) after an ICA occlusion is

an even rarer phenomenon, but may occur more

frequently than expected,5-8 and can result in fur-

ther cerebrovascular events.9 In this study, we

report a case of ICA occlusion diagnosed after a

neurological event, which subsequently underwent

late recanalization; the patient underwent success-

ful carotid endarterectomy (CEA).

CASE REPORT

A 74-year-old man with a past medical history of type II

diabetes mellitus, hypertension, and atrial fibrillation

iginal article: 10.1016/j.avsg.2010.03.012.

ence : Parth S. Shah, Division of Vascular Surgery,edical Center, 4802 10th Ave, Brooklyn, NY 11219,pshah2@maimonidesmed.org

2010; 24: 954.e1-954.e4j.acvfr.2011.02.024ascular Surgery Inc.EVIER MASSON SAS

was admitted in January 2008 with acute left frontoparie-

tal infarction with right-sided hemiparesis. The work-up

revealed occlusion of the left ICA on carotid duplex scan

(Fig. 1). This was confirmed on computerized tomo-

graphic angiography (Fig. 2) and carotid angiogram

(Fig. 3). The patient was medically managed and had

complete neurological recovery. Of note, the contralateral

ICA demonstrated 85% stenosis on duplex imaging.

The patient presented again in August 2008 with syn-

cope. There were no focal neurological deficits or abnor-

mal physical findings. A computed tomography (CT)

scan of the head showed no new intracranial findings.

However, duplex scan of the left ICA (Fig. 4) revealed

severe calcification and peak systolic velocity of 562 cm/

sec suggestive of severe stenosis. The distal ICA was

patent.

The patient underwent surgical exploration. The left

ICA was found to be severely stenotic secondary to athe-

rosclerotic plaque at the carotid bifurcation. Successful

left CEA was performed with the use of internal shunt

and Dacron patch angioplasty. The postoperative course

was complicated by the development of surgical site

hematoma on resuming anticoagulation for atrial fibrilla-

tion. The hematoma subsequently resolved with tempo-

rary cessation of anticoagulation and the patient was

discharged home in stable condition on anticoagulation.

The patient was readmitted with the signs of cerebral

hyperperfusion syndrome evident by confusion and a

1037.e15

Fig. 1. A, B Color-coded duplex ultrasonography in

January 2008, showing complete occlusion of left ICA.

Fig. 2. Computerized tomographic angiography done in

January 2008. The arrow showing occlusion of left ICA.

Fig. 3. Cerebral angiogram. The large arrow is showing

occlusion of left ICA with retrograde filling. The small

arrow is showing patent left external carotid artery.

1037.e16 Cas cliniques Annales de chirurgie vasculaire

seizure episode associated with uncontrolled hyperten-

sion (BP: 190/90 mm Hg) on the postoperative day 8. A

CT scan of the head was obtained and was negative for

any acute intracranial event. A carotid duplex scan revea-

led routine postoperative changes and no evidence of

thrombosis. The patient responded well with medical

treatment and was discharged home. Currently, the

patient is doing well at the end of 1-year follow-up. The

patient, later, underwent an uneventful right-sided CEA

in March 2009.

DISCUSSION

Spontaneous recanalization of arterial occlusions is

a rare and rather infrequently reported phenome-

non. There is meager evidence in the published

data exploring the natural history, incidence, mana-

gement, and cost-effectiveness of surveillance of the

chronic arterial occlusions. There have been isolated

case reports and some anecdotal evidence on spon-

taneous recanalization of aortic and peripheral

arterial occlusions. In a case series, Gargiulo et al.10

described recanalization of the infrainguinal arterial

occlusions. The diagnosis was made incidentally by

angiogram, duplex ultrasonography, and magnetic

resonance/CT angiography as a work-up of various

presentations.

The entity of late spontaneous recanalization of an

ICA occlusion has also been described. If carotid ste-

nosis progresses to acute occlusion, the risk of stroke

is as high as 25%,11 although after the occlusion has

been established, the risk of subsequent stroke is

relatively low.12-14 In a large retrospective study, it

was shown that asymptomatic chronic carotid artery

Fig. 4. Color-coded duplex ultrasonography in August

2008. A Severe stenosis of left ICA at carotid bifurcation

with high peak systolic velocities (PSV) upto 562 cm/sec.

B Patent distal left ICA.

Vol. 24, No. 7, 2010 Cas cliniques 1037.e17

occlusions have annual stroke rate of 2.3%,15 and

hence no intervention is offered to those patients.

Stroke carries a significant morbidity and disability as

well as the risk of mortality. In a retrospective study,

Paciaroni et al.16 demonstrated that after a mean

follow-upof1.2years,45%of thepatientswith stroke

associated with an acute ICA occlusion had died,

whereas 30% were functionally dependent. In this

report, the spontaneous recanalization of an acutely

occluded ICA was associated with cardioembolism

and arterial dissection.15,17 Prior case reports have

also demonstrated that spontaneous recanalization of

the ICA after a chronic occlusion can occur and result

in successful CEA.2,7

Spontaneous fibrinolysis of the acute occlusions

on the pre-existing severe atherosclerotic stenosis

of the native vessel is the most plausible mechanism

in our case. The activation of spontaneous endo-

thelial antithrombotic mechanisms may allow the

thrombolysis.18 Another plausible mechanism of

recanalization would be a superimposed occlusion

in the setting of pre-existing severely stenotic ICA

and subsequent fibrinolysis may result in recanali-

zation. Therefore, we recommend close surveillance

of the occlusions. There is no evidence suggesting

the frequency and length of surveillance. There is

evidence supporting performing routine color-

coded duplex sonography in the follow-up of

stroke patients as spontaneous recanalization may

influence clinical outcome.4We suggest that follow-

up every 6 months by duplex imaging of an occlu-

ded and the contralateral ICA is a reasonable

approach until further evidence is available.19,20

In conclusion, our case reports the existence of

the rare, yet possible, phenomenon of spontaneous

recanalization of carotid occlusions.5 Further

research is needed to understand the natural his-

tory, incidence, specificity of imaging modalities,

clinical outcomes, and alternatives of treatment for

carotid occlusions.

REFERENCES

1. Szabo K, Kern R, Gass A, et al. Early spontaneous recana-

lization following acute carotid occlusion. J Neuroimaging

2008;18:148-153.

2. Calleja S, De la Vega V, Llaneza JM, Lopez-Roger R,

Gutierrez JM, Lahoz CH. Spontaneous recanalization of

acute internal carotid artery occlusion. Ann Vasc Surg

2004;18:490-492.

3. Nguyen-Huynh MN, Lev MH, Rordorf G. Spontaneous

recanalization of internal carotid artery occlusion. Stroke

2003;34:1032-1034.

4. Meves SH, Muhs A, Federlein J, B€uttner T, Przuntek H,

Postert T. Recanalization of acute symptomatic occlusions of

the internal carotid artery. J Neurol 2002;249:188-192.

5. Markwalder TM, Starrett RW, Mumenthaler M. Sponta-

neous bilateral recanalization in bilateral internal carotid

artery occlusion. Stroke 1980;11:95-98.

6. Camporese G, Verlato F, Salmistraro G, Ragazzi R,

Andreozzi GM. Spontaneous recanalization of internal

carotid artery occlusion evaluated with color flow imaging

and contrast arteriography. Int Angiol 2003;22:64-71.

7. Matic P, Ilijevski N, Radak S, Kolar J, Radak D. Recanali-

zation of chronic carotid occlusion: case report and review of

the literature. Vascular 2009;17:281-283.

8. Klonaris C, Alexandrou A, Katsargyris A, Liasis N,

Bastounis E. Late spontaneous recanalization of acute

internal carotid artery occlusion. J Vasc Surg 2006;43:

844-847.

9. Binning MJ, Jackson G, Couldwell WT. Spontaneous reca-

nalization of the internal carotid artery resulting in throm-

boembolic occlusion of the ipsilateral ophthalmic artery and

visual loss. J Clin Neurosci 2009;16:1244-1246.

10. Gargiulo NJ 3rd, Veith FJ, Lipsitz EC, et al. Spontaneous

recanalization of arterial occlusions: an unusual mechanism

for symptomatic improvement. J Vasc Surg 2002;36:

1161-1166.

11. Nicholls SC, Bergelin R, Strandness DE. Neurologic sequelae

of unilateral carotid artery occlusion: immediate and late. J

Vasc Surg 1989;10:542-547.

12. Cote R, Barnett HJ, Taylor DW. Internal carotid occlusion: a

prospective study. Stroke 1983;14:898-902.

1037.e18 Cas cliniques Annales de chirurgie vasculaire

13. AbuRahma AF, Stone PA, Abu-Halimah S, Welch CA.

Natural history of carotid artery occlusion contralateral to

carotid endarterectomy. J Vasc Surg 2006;44:62-66.

14. Persson AV, Griffey EE. The natural history of total occlu-

sion of the internal carotid artery. Surg Clin North Am

1985;65:411-416.

15. Meissner I, Wiebers DO, Whisnant JP, O’Fallon WM. The

natural history of asymptomatic carotid artery occlusive

lesions. JAMA 1987;258:2704-2707.

16. Paciaroni M, Caso V, Venti M, et al. Outcome in patients

with stroke associated with internal carotid artery occlusion.

Cerebrovasc Dis 2005;20:108-113.

17. Parenti G, Marconi F, Canapicchi R, Puglioli M, Giraldi C.

Spontaneous recanalization of carotid artery occlusion

following non traumatic dissection. Ital J Neurol Sci

1989;10:361-367.

18. Manganaro A, Ruggeri M, Ando G, Longo M, Vita G.

Endothelial functions in pathophysiology of thrombosis and

fibrinolysis: late spontaneous recanalization of an occluded

internal carotid arteryda case report. Angiology 2002;53:

99-103.

19. Lee DH, Gao FQ, Rankin RN, Pelz DM, Fox AJ. Duplex and

color Doppler flow sonography of occlusion and near

occlusion of the carotid artery. Am J Neuroradiol 1996;17:

1267-1274.

20. Gortler M, Niethammer R, Widder B. Differentiating sub-

total carotid artery stenoses from occlusions by colour-coded

duplex sonography. J Neurol 1994;241:301-305.